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Obtaining old records

  1. Smile Obtaining old records
    Medical Coding Books
    In MDM table and under review of data we have1

    1)Decision to obtain old records - 1 point.

    2) Review of old records - 2 points.

    How the above mentioned scenarios will be documented in the report and where it will be found (whether in History or MDM)?

  2. #2
    Swainsboro/Statesboro, GA
    There is no mandated place where this info would have to be documented. Usually, you would see the decision to request old records in the Plan, but it could also be in the History. If the physician already had the records from another physician (the patient brought them or they had been mailed prior to the visit), you may see the review and summary with the History or with the Assessment and Plan.

    What you need to make sure of is that the info is only counted in one component of the level.
    Freda Brinson, CPC, COC, CEMC
    AAPC Swainsboro/Statesboro Chapter
    2017/2018 Secretary/Treasurer
    2016 Education Officer
    2014/2015 President
    Past President - 2012, 2008; Past Vice President - 2013, Past Education Officer - 2009 of Savannah, GA Chapter
    Past Member AAPCCA Board of Directors (2009-2012)

  3. #3
    You may find a notation like "Per Dr. ABC's office note/s from (date/s) the patient has .... (issues/treatments/etc)" - this is most likely found in the beginning of the note (history part). Credit 2 points if summarized.
    You may see a notation like "we will request the ____report(s) from XYZ-hospital" - this is most likely to appear towards the end (A/P part). Credit 1 point.
    Karolina, CPC, CPMA, CEMC

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